2021年英文病例写作范文阅读带翻译

1、英文病例写作范文篇一Name: Joe Bloggs （姓名乔。伯劳格斯）Date: 1st January 2000日期（2000年 1 月 1 日）Time: 0720（时间7 时 20分）Place: AE（地点事故与急诊登记处）Age: 47 years什龄 47 岁）Sex: maleG生另1J男）Occupation: HGV（heavy goods vehicle ） driver龈业大型货运卡车司机）PC（presenting complaint）住诉）4-hour crushing retrosternal chest pair®骨后压榨性疼痛 4 小时）HPC（h

2、istory of presenting complaint）（ffl 病史）Onset: 4 hours of crushing tight retrosternal chest pain, radiating to neck and both arms, gradual onset over 5-10 minutes超病特征胸骨后压榨性疼痛 4小时， 向颈与双臂放射，5-10分钟内渐起病）Duration: persistent since 0nset1期发病起持续至今 ）Severe: worst pain ever haW重性从未痛得如此厉害过）Relieving/exacerbati

3、ng factors 解与恶化因素GTN（glyceryl trinitrate） provided no relief although normally relieves pain in minutes, no other relieving/exacerbating factors.蜡酸甘油平时能在数分钟内缓解 疼痛，但本次无效，无其它缓解和恶化因素。 ）英文病例写作范文篇二Nausea, vomiting2, sweating, dizzy恶心、呕吐 2 次、出汗、眩晕） 1997:external chest tightness and dyspnea initially contr

4、olled atenolol.1997年出现胸外疼痛与呼吸困难，最终经服 atenolol控制。4/12 symptoms worse, exercise tolerance 200 yards on flat, limited by chest pain4月 12 日，症状加重，受胸痛限制，仅耐受平地行走200码No rest pain, no orthopnoea, no PND无静息时疼痛，无端坐呼吸、无阵发性夜间呼吸困难英文病例写作范文篇三Hypertension-no 高血压无Smoking-20 cigarettes per day for 16 years烟 16 年来每天 20

5、 支Diabetes-no糖尿病无Cholesterol-never checked且固醇未查Ischemic heart disease-angina, previous Mft血性心脏病心绞痛、有心肌梗 死病史PMH（past medical historyM 去史1963: appendectomy 1963年阑尾切除手术1972: duodenal ulcer, no symptoms since197笄十二指肠溃疡，之后无症状1986: myocardial infarction, full recovery / No subsequent investigation1986 心肌梗

6、死，完全恢复，无随访1989: gout quiescent on treatment198笄痛风治疗期间症状静止No diabetes, hypertension, rheumatic heart disease, tuberculosis, epilepsy, asthma, jaundice, cerebrovascular disease®尿病、高血压、风湿性心脏病、结 核病、癫痫、哮喘、黄疸、脑血管疾病S/E(systems inquiry)系统回顾英文病例写作范文篇四Fatigue lately, appetite unchanged, weight stable, no

7、 sweats or pruritus, sleeping well最近有疲劳感，食欲无改变，体重稳定，无出汗或骚痒，睡眠佳。RS 呼吸系统Dyspnea on exertion, particularly uphill, but not limiting; no cough sputum/wheeze劳累时呼吸困难，上坡尤其如此，但无呼吸限制，无咳嗽咳痰、哮喘。GIT gastrointestinal tract 胃肠道No current indigestion 现无消化不良。No symptoms lile previous duodenal ulcerM去无十二指肠溃疡症状。No vo

8、miting/dysphagia/abdominal pain无呕吐、吞咽困难、腹部疼痛。GUS genitourinary system 生殖泌尿道No urinary systems无泌尿道症状。英文病例写作范文篇五Atenolol 100 mg once daily(Atenolol 100mg 每天 1 次)GTN as required需要服用硝酸甘油。Not taking aspirin 无服用过阿斯匹林。Allergies: penicillin-skin rash 过敏反应青霉素 皮疹。FH(family history) 家族史Father died of heart att

9、ack at age 5父亲 53 岁死于心脏病。Mother died of old age at 7母亲于 76 岁去世。SH(social history)社会史Lives with wife who fit and well. 妻子健在，与其共同生活。Own house 私宅。Completely independent 生活全部自理。Smoking 20 cigs/day for many years年每天抽烟 20 支。Alcohol: 24 units per week饮酒每周 24个单位。Sexual history: not appropriate 性生活未评价。Overse

10、as travel: not appropriate!外旅游未评价。Pets: not appropriated物未评价。Occupation: heavy goods vehicle driveSR 业大型货车卡车司机。O/E(on examination淋检结果英文病例写作范文篇六Unwell, sweaty, clammy, no cyanosis/jaundice一般情况不佳，出汗、皮肤湿冷，无青紫、黄疸。temperature: 35体温 35 。cigarette-stained fingers烟熏手指。no arcus / xanthomas / xanthelasma无老人弓环

11、、黄瘤、黄斑瘤。CVS 心血管系统Pluse 104 bpm regular, normal character脉搏每分钟 104 次，规则，心音正常。BP110/70 mmHg (right), 112/74 mmHg (left)血压 110/70 mmHg 右，112/74 mmHg 左。JVP(jugular venous pulse) normal颈静脉博动正常。No precordial scars /chest deformities无心前区疤痕、胸廓畸形。Apex beat displaced to anterior axillarys line 6th intercostals space心尖博动向腋前线第6 肋间移位。No parasternal heave /thrills无胸骨旁隆起、震颤。Auscultation: heart sounds normal, but soft pan systolic murmur at apex radiating to axilla听诊心音正常，但心尖问及收缩前柔和杂音，向腋窝放射。PSM at apex and ejection systolic murmur in aortic area